License application form ny

The New York State Education Department (“SED”) Office of the Professions (“OP”) is alerting everyone to a vishing scam that has been brought to our attention. Phishing—or “vishing”—scams impersonate SED employees or websites attempting to collect licensure and personal information from the licensee. If you receive an inquiry which you believe to be suspicious do not provide any information. To verify if the inquiry was from OP, contact OP directly using the following contact information. You may report any suspicious communication received to the Federal Trade Commission.

License Application Forms for Physicians

Physicians

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Important Notice: DO NOT use Form 1 if you are already licensed in this profession in New York State. A New York State professional license is valid for life unless it is revoked, annulled, or suspended by the Board of Regents. To practice in New York State, your professional license must be registered. To renew your registration online, visit http://op.nysed.gov/services/online-registration-renewal. If your registration has lapsed for longer than 4 months, submit a Delayed Registration Application.

Applicant Checklist

You may print and keep this checklist as a reminder of what forms you need to file. This is for your reference and should not be submitted with your application forms. You should also keep a copy of all application forms submitted.

Online Form 1 - Application for Licensure

All applicants for licensure must initially submit Form 1 along with the $735 licensure and first registration fee. You must answer all questions and provide all information requested unless otherwise indicated. Failure to accurately complete all required parts of the application will delay its review. Additional forms below are required based on the licensure requirements of the profession. Do not use Form 1 to renew your existing license.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID, Social Security Number, and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Change Address or Name You are required to notify us within 30 days of any address or name changes. Please read the instructions to request this change.

Form 2 - Certification of Professional and Preprofessional Education

PLEASE NOTE: If you are not using FCVS, you must have your educational institution send this form directly to the Office of the Professions. We will not accept this form if it is submitted by the applicant or a third party.

Graduates of programs not registered as licensure qualifying by New York State or accredited by the Liaison Committee on Medical Education (LCME), or the American Osteopathic Association (AOA), or the Committee on the Accreditation of Canadian Medical Schools (CACMS) - do not use this form. You must use FCVS to collect your credentials.

Please make as many copies of Form 2 as needed.

Electronic Education Documentation

The Office of the Professions (OP) will accept official electronic transcripts and forms from educational institutions (i.e. colleges/universities) or designated third-party* transcript entities located in the United States, Canada, Brazil and the Philippines provided that:

*OP will only accept third-party submissions after we have determined that the arrangement between the educational institution and the third party is consistent with our security and verification standards.

**Transcript documents with expiration dates cannot be accepted. Expirations on links to the document are acceptable.

***Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Form 2CC - Certification of Approved Clinical Clerkship

Use this form only if you are a graduate of a non-LCME-accredited medical school located in one country but completed one or more clinical clerkships in another country.

Please Note: This form must be mailed directly to the Office of the Professions by the hospital in its identifying envelope. We will not accept this form if it is submitted by the applicant or a third party.

The New York State Education Department has approved specific schools to allow students to complete more than 12 weeks of clinical clerkships in New York State. A list of these schools can be found here. Form 2CC is not needed for those graduates who completed all clerkships after the approval date listed. Note: Form 2CC is required for any clerkships completed prior to that approval date.

Former students of CIFAS, CETEC, and UTESA should not use Form 2CC. These applicants should request special clerkship verification forms from the Office of the Professions, Bureau of Comparative Education at (518) 474-3817 ext. 300 or by e-mail at comped@nysed.gov.

Please make as many copies of Form 2CC as needed.

Form 2PGT - Certification of Approved Postgraduate Training*

Use this form only if you are not using FCVS.

Please Note: This form must be mailed directly to the Office of the Professions by the hospital in its identifying envelope. Documentation of postgraduate training can only be accepted if signed less than one month prior to the completion date of the training period for which credit is sought. If you or a third party send this form, we will take no further action until we receive direct verification from the hospital.

Please make as many copies of Form 2PGT as needed.

*Approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Royal College of Physicians and Surgeons of Canada.

Form 3A - Verification of Medical Licensure in Another Country

Use this form only if you were licensed and practiced medicine in another country within the 5-year period immediately prior to the date of your application for licensure or a limited permit in New York State.

Please Note: This form must be sent to the Office of the Professions by the licensing jurisdiction. We will not accept this form if it is submitted by the applicant or a third party.

Please make as many copies of Form 3A as needed.

Form 3B - Verification of Pre-1972 Medical Licensure in Another U.S. State or Territory

Use this form only if you are requesting endorsement of a medical license based on a pre-1972 state licensing examination.

Please Note: This form must be sent to the Office of the Professions by the licensing jurisdiction. We will not accept this form if it is submitted by the applicant or a third party.

Electronic Verification of Licensure, Certification and/or Examination

The Office of the Professions (OP) will accept electronic verifications of licensure, certification and examination completion from other licensing authorities located in the United States provided that:

*DO NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Form 4 - Verification of Professional Practice of Medicine in Another Jurisdiction

Use this form only if you are requesting licensure based on endorsement of another license.

Please Note: This form must be sent to the Office of the Professions by the licensed physician verifying your practice. We will not accept this form if it is submitted by the applicant.

Please make as many copies of Form 4 as needed.

Electronic Verification of Experience

The Office of the Professions (OP) will accept experience forms directly from supervisors provided that:

*Do NOT use this email to submit a question, as we will be unable to provide a response. Submit a Contact Us Form for questions regarding specific applications or to check the status of a licensure application.

Online Form 5A - Application for Limited Permit

All applicants for a limited permit who also seek licensure in New York State must initially submit Form 5A along with the $105 limited permit fee. You must also submit a Form 5CS - Certification of Supervision for Limited Permit along with your application.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Employment or Practice Status
If there is a change of employment or practice status, you must obtain an amended permit using the Limited Permit Change Form and submit a Form 5CS. After changes are processed you will receive an amended permit. An additional fee is not required (see Upload Additional Documentation above). Note: A permit authorizing practice in one facility MAY NOT be used in another facility without prior approval by the Department.

Online Form 5B - Application for Limited Permit

All applicants for a limited permit who ARE NOT seeking licensure in New York State must initially submit Form 5B along with the $105 limited permit fee. You must also submit a Form 5CS - Certification of Supervision for Limited Permit along with your application.

Continuing Your Application
If you have started an application within the past 30 days, and have not yet completed it, you can use this link to continue your application. You will need your Application ID and Date of Birth.

Upload Additional Documentation
If you have already completed an application, but you have additional documents or files to include in your previous submission, use this link to upload additional documentation. You will need your Application ID and Date of Birth.

Changes to Employment or Practice Status
If there is a change of employment or practice status, you must obtain an amended permit using the Limited Permit Change Form and submit a Form 5CS. After changes are processed you will receive an amended permit. An additional fee is not required (see Upload Additional Documentation above). Note: A permit authorizing practice in one facility MAY NOT be used in another facility without prior approval by the Department.

Form 5CS - Certification of Supervision for Employment

Use this form ONLY if you are applying/have applied for a New York State Limited Permit as a Physician.

• Section I: Complete this section.
• Section II: Your employer must complete this section before you can submit it to the Office of the Professions at the appropriate address at the end of the form. It is your responsibility to ensure your employer fully completes Section II. Failure to complete this form will delay its review.